EHV-1 Screening Form

HealthEquine Therapies EHV-1 Screening Form

Please read thoroughly and fill out all fields
As there has been several active cases of EHV-1 in Southern, Ontario, we want you to feel confident with our services, by knowing we are being vigilant and implementing extra biosecurity measures to our already established COVID-19 protocols, to keep our clients safe. Transparency is key, with communication and honesty being the best way to stop the spread.
Full Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Does your horse have any of the following symptoms of EHV-1?: *

Fever Pain Nasal discharge Lethargy/Depression Neurological disease No symptoms
Has your horse traveled outside your barn facility in the last 14 days?

Yes No
Has your horse had close contact with another horse who has a confirmed or probable EHV-1 case?

Yes No
Are any horses at your barn facility suspected or showing symptoms of EHV-1? *

Yes No Not sure
Have any new horses moved into your barn in the last 14 days? *

Yes No Not Sure
Date

Month Day Year
Date
Signature

Clear
Should be Empty:

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HealthEquine Therapies EHV-1 Screening Form